Tuesday, June 26, 2012

This Is A Good One

I found this one here;

Did you ever wonder why your medical records ALL invariably say "pt. tolerated procedure well" even though there were lots of problems?  You should read this piece!  This was on a crna site, where of course they want to bash doctors, MDA's or a-n-e-s-t-h-e-s-i-o-l-o-g-i-s-t-s (something the nurses are NOT) but it is alarming!

Please note that my crna did NOT follow the guidelines expressed in the above link either.   I was going to pick out just ONE of these, the last one, but my crna didn't comply fully with ANY of these.   He obeyed parts of #'s 1 and 4, but not all of it.   The rest of it?  Don't make me laugh.

"...mandatory elements of the intra-operative record:

* Name, dosage, route and time of administration of drugs and anesthesia agents;
* Techniques(s) used and patient position(s), including the insertion/use of any intravascular or airway devices;
* Name and amounts of IV fluids, including blood or blood products if applicable;
* Timed-based documentation of vital signs as well as oxygenation and ventilation parameters; and
* Any complications, adverse reactions, or problems occurring during anesthesia, including time and description of symptoms, vital signs, treatments rendered, and patient’s response to treatment."

You can look at my medical records, a copy of which is in this blog.  I hope that nobody says that I don't have ALL the records!  Because that would mean yet more laws were broken.  I have an absolute right to any and all records, not just the ones cherry picked by the medical people themselves.

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